"Alerted.org

Resp & Qualifications

**PURPOSE** :

Supervise the daily operations of the utilization management (UM) department functions to ensure appropriate coordination of health care services and compliance with UR policies/procedures, as well as regulatory and CareFirst's accreditation standards. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

+ Supervise the daily operations of the UM staff. Recruits, retains and develops a high performing team. Evaluates performance of each team member, generates development plans and sets goals within the context of the corporate policies and procedures. Ensure appropriate usage of resources in order to facilitate the UM process. Educate staff as necessary to ensure consistent performance and adhere to standards.

+ Ensure compliance within applicable state program guidelines. Evaluate compliance policies and procedures and analyze/recommend enhancements.

+ Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements

+ Identify opportunities for process improvements necessary to facilitate department functions

+ Communicates in a timely manner to Manager appropriate information including, but not limited to, customer/case issues, reports, trends/variances, action plans, etc.

SUPERVISORY RESPONSIBILITY:

This position manages people.

QUALIFICATIONS:

**Education Level:** Bachelor's Degree in Nursing or health care field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Licenses/Certifications Upon Hire Required:

+ RN - Registered Nurse - State Licensure And/or Compact State Licensure.

**Experience:** 3 years Medical/surgical experience including, but not limited to, inpatient care, outpatient/home care and hospice care, and experience reviewing patient medical care. Demonstrated leadership skills.

Preferred Qualifications:

+ 5+ years of UM experience in a lead or supervisor role with a healthcare payor organization. Experience working with both commercial and government programs lines of business.

Knowledge, Skills and Abilities (KSAs)

+ Oversight of Utilization Management clinicians while championing process improvement, change adoption and the use of data to drive decisions.Ability to balance quality, productivity, compliance and member/provider experience in daily decision-making.

+ Knowledge of accreditation standards and federal/state regulations and general principles relating to utilization review.

+ Computer skills, including Microsoft Office programs.

+ Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.

+ Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.

+ Excellent analytical, problem-solving skills with ability to judge appropriateness of member services and treatments on a case-by-case basis.

+ Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.

+ Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

**Salary Range:** $78,696 - $162,311

Travel Requirements

**Estimate Amount:** 5% Able to travel to CareFirst sites for meetings and off-site Health Services meetings

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Clinical Utilization Management

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

\#LI-SS1

REQNUMBER: 21522